The next debate on our agenda this afternoon is the debate on the Health, Social Care and Sport Committee's report on dentistry in Wales, and I call on the Chair of the committee to move the motion. Dai Lloyd.

Motion NDM7150 Dai Lloyd

To propose that the National Assembly for Wales:

Notes the report of the Health, Social Care and Sport Committee:  A Fresh Start: Inquiry into dentistry in Wales, which was laid in the Table Office on 21 May 2019.

Motion moved.

Thank you very much, Deputy Presiding Officer. I am very pleased to take part in today’s debate on the Health, Social Care and Sport Committee’s report on dentistry in Wales. This is the second of the committee’s reports in a series of spotlight inquiries on health issues that are vitally important to the people of Wales.

The committee agreed to undertake a one-day inquiry to shine a light on dental and orthodontic services in Wales, along with wider workforce issues within the dental profession, including training places and recruitment. We published our report in May of this year and made six recommendations to the Welsh Government. I am pleased that the Minister has accepted all six of them, and I look forward to the Minister’s response today, which I am sure will provide some of the detail around how he will remedy the enduring problems of patient access to dental services and the profession’s long-standing dissatisfaction with the contract system.

The NHS general dental services contract came into force in 2006 in England and Wales. The contract pays dentists an annual amount for their NHS work through a unit of dental activity system. Now, this system consists of three bands that determine how much a patient is charged for their treatment and how much a dental practice is then remunerated. The payment is the same whether a dentist undertakes one or more similar procedures. The committee was told that there is no incentive for dentists to take on high-needs patients, as they would be paid the same amount for doing more work. This has clear implications for access to dentistry in Wales. We are concerned that the current UDA system may be discouraging dentists from taking on high-needs patients, particularly where poorer access to dental services already exists in Wales.

The Welsh Government has previously made changes to the UDA-based model, with the use of pilot schemes to test a reduction in UDA targets to allow dentists more flexibility and space to undertake preventative work. However, we heard clear concerns from dentists themselves that the changes to dental contracts over the last decade have not had much impact. That is why the committee’s first recommendation is to replace the current UDA targets system with a new, more appropriate and more flexible system for monitoring outcomes, to include a focus on prevention and quality of treatment. As I said, this system will focus on prevention and quality of treatment. We look forward to receiving an update from the Minister in November on progress in this area.

As part of the dental contract, practices are evaluated on the UDAs they achieve against their contracted allowance of UDAs allocated by their health board. The contract requires health boards to pay a dental practice 100 per cent if it has delivered at least 95 per cent of its contractual activity as expressed in its UDA. This is the percentage of activity that must be delivered if a practice is to avoid the health board clawing back funds. The committee heard in evidence that this clawback is not universally reinvested by health boards back into dentistry services. We believe that dentistry services in Wales could be further improved through the reinvestment of this money, and we recommend that the Welsh Government takes steps to ensure and monitor that all health boards reinvest this money until a new system for monitoring outcomes is in place, as recommended by this committee

A number of the available career pathways in Wales, including dental foundation training, dental core training and specialist training, are now part of UK-wide recruitment. We were pleased to learn that there are no major issues with recruitment into dental schools in Wales, although we are aware that these figures can be low for Welsh-domiciled students. The committee also heard evidence about the challenges with retaining dentists to work in Wales following their training period. We are aware that some of the barriers are the difference in salary in Wales compared to England, along with health boards' proximity to the dental school. We urge the Welsh Government to consider successful initiatives being used elsewhere in the UK to address issues of recruitment and retention. As such, our third recommendation is that the Welsh Government undertakes an evaluation of the UK-wide recruitment scheme to determine if it is effectively supporting an increase in Welsh-domiciled students and the retention of students following training. In his written response to our report, the Minister accepts that an evaluation is required and that he will discuss with Health Education and Improvement Wales how to take this forward. I look forward to hearing more detail about this today.

Turning to orthodontic services, the committee heard that inappropriate referrals to orthodontic services can put a strain on services and exacerbate waiting times issues. While we recognise that, primarily, long waiting times are as a result of recruitment issues, we are concerned about the method of referring and prioritising patients. We heard that some primary care dental practitioners refer patients too early in order to take account of long waiting times. This inevitably adds to the problem. We note the introduction of the electronic referral management system and recognise that, while the system may not increase capacity, we would expect it to have a positive impact on ensuring appropriate referrals, prioritising patients and reducing waiting times. The committee therefore recommends that the Welsh Government works with health boards to develop a clear strategy to ensure that the e-referral system for orthodontic services has a positive impact on ensuring appropriate referrals, prioritising patients and reducing waiting times.

Turning to the Designed to Smile scheme, the committee recognises the positive impact of Designed to Smile, which is the national oral health improvement programme for children in Wales. We welcome the extension of the programme to include very young children. However, the committee heard concerns around the Welsh Government’s refocus of this programme, placing more emphasis on children aged nought to five years, and a possible shift away from children above that age. As such, we recommend that the Welsh Government should fund the Designed to Smile programme sufficiently to ensure that those over five years of age receive its benefits. In his written response, the Minister refers to apparent misconceptions that, as a result of the refocus, those aged six and seven are being denied the benefits of the programme. I look forward to hearing more from him on this matter this afternoon.

We heard strong evidence that the oral health issues in older children and young teenagers can lead to the loss of permanent teeth. In some cases, many teeth are lost, and the committee expects effective action to be taken to address this. The committee is aware that the Welsh Government has commissioned an epidemiological study with the aim of assessing and understanding the needs of the 12 to 21 age group and to help inform future approaches to meet the needs of this age group. So, I look forward to receiving an update from the Minister on this area of work. Thank you.

I'm grateful to be able to speak on the committee's report. I'm delighted, actually, we did this one-day report, because it shone a light on a part of the NHS here in Wales that is so very vital to people's long-term health and yet sometimes is really overlooked. And I'm pleased that the Government has accepted all the recommendations, although I do have commentary on that. 

'Everyone should have access to good-quality NHS dental services'. This is the headline on the Government's Health in Wales website page on how to find a dentist. Now, that's quite tricky in an awful lot of Wales. About 45 per cent of the population—that's almost 1.5 million individuals—have not seen a high street NHS dentist in the last two years. And I'm concerned about the stagnation that these figures actually show up, because, nine years ago, 55 per cent of the population was being treated within the NHS dentistry service. Today, 55 per cent of the population is being treated in the NHS dentistry service. That sounds like good news, doesn't it, but, of course, our population's grown by almost 200,000, so, actually, we're beginning to reverse and, rather than reverse or stagnate, we need to improve.

So, Minister, I'd be very grateful if you could just talk us through how you think we're going to be able to address this and increase the numbers of people who are having access to NHS dentistry services. Because, in my constituency, there is no dental practice that is accepting new adult or child NHS patients whatsoever. Only 15.5 per cent of NHS practices throughout Wales are currently accepting adult NHS patients, and only 27 per cent are accepting new children, which, actually, is really bad news for a couple of reasons. One is it actually starts to negate all the positive work in Designed to Smile, because there's no encouragement to carry it on. Two, every time you go into a hospital, you're asked about the state of your teeth. It's absolutely vital and it's recognised by the medical profession. They promote the fact that, unless you have good, healthy teeth, you are liable to open yourself up to all manner of infections and tendencies for heart failure and all the rest of it. So, unless we have really, really good teeth and we keep our teeth healthy, then we are opening ourselves up to further illnesses. So, we're immediately setting ourselves up to fail if we do not give people access to good dentistry. 

And it's not a snapshot in time. I noted in your response that you said this was a snapshot, but this is two different years that all this has been monitored over. So, what's the real problem? Well, the real problem is there's no new money. All the recommendations you've accepted, which is great, but none of the recommendations have any financial implication whatsoever, which means there is no new money. The value of the total dental budget in 2017-18 is worth 15 per cent less in real terms compared to the budget six years ago, but I can assure you that in the six years capital costs have increased, staff costs have increased, everything else has increased. So, of course, what's happening is that the patient is being squeezed, services to the patient are being squeezed. An expenditure of £186.7 million in 2012-13, which is what we spent, should equate to £216.57 million now, and that's just to keep pace with inflation. Our six-year shortfall for last year was over £29 million, and £29 million in a small part of the NHS sector like this actually makes for an awful lot of money that can make an awful lot of difference. So, I'm deeply concerned about the fact that we have no new money.

The other point that also concerns me, and pertains to our recommendation 1, is about the fact that there are still pilot practices—or there's still a desire by the chief dental officer to implement new pilot practices to test how we ought to relook at the unit of dental activity. What I don't understand about this is that some years ago, I had the great good fortune to go down to some pilots that were being run by the Welsh Government in Swansea, and there's been one elsewhere—very successful. It absolutely looked at people in the round, it looked at the holistic way of being able to measure their dental health. The downside was that it was highly preventative, so they saw slightly fewer patients, but in the long term the benefit to Wales, to the dental service, was absolutely outstanding. I would be very grateful, Minister, if you could just clarify why you've not gone ahead with any of those pilots that were tested and seen to be positive, but instead we are waiting and waiting and waiting, and spending yet more time in trying to redesign the wheel and come up with yet another alternative, when we seem to have some very successful ones that your Government came up with not so very long ago.    

Members will be aware that I have been asking questions about the dental situation in my constituency of Arfon on a number of occasions, and it is a very grave situation indeed. There are six practitioners in the constituency, but none of them are taking NHS patients. They’re not taking adults on the NHS, they’re not taking children on the NHS and they’re not taking children and young people with disabilities on the NHS, either. So, many of them have to go out of the area to seek dental treatment on the NHS—as far as Dolgellau in some cases, which is an hour and a quarter away in a car, and takes even longer, of course, on a bus.

What that means on a practical level very often is that the patients wait until things have gone to an extreme, and have to go to an emergency clinic through NHS Direct once the problem has worsened. And then, that clinic, very often, is at least half an hour away in a car from people’s homes in Arfon. Or, if they can’t get to the clinic, what happens next is that they turn up at Ysbyty Gwynedd with serious problems. Anecdotally, I hear regular stories about such situations; it’s increasing in how often it happens. Therefore, the relatively cheap preventative work simply isn’t happening, and what happens is that it becomes an acute emergency case, which, of course, is very expensive. What’s very frustrating for dental practitioners in Arfon is that they do have capacity; they have the time to see patients. Half of them do accept private patients, so they have the resources, but they can’t take new NHS patients because the contract places a cap on the number of NHS patients that they can accept. They won’t be paid if they go beyond that limit.

The situation hasn’t changed in the past two years. It's wrong to say that the picture I'm painting today is a snapshot, as has been claimed when I have raised this issue previously. The situation is very similar to what it was two years ago. So, I am extremely disappointed that there will be no additional funding and I’m exceptionally disappointed that the move towards better contracts for dentistry on the NHS—that that movement is so slow. That’s what the practitioners are telling me in Arfon, too. Therefore, the situation facing new patients and children in my area will continue, despite the best efforts of the committee and this one-day inquiry that you’ve held. It appears that you’ve been wasting your time, because the Government doesn’t intend to do anything that’s hugely different to what they’re doing at the moment, and the dental crisis will continue.

I am pleased to hear that there is to be an evaluation of recruitment and retention among dentists, and I look forward to seeing the conclusions of that. I would like to ask today whether you will be looking specifically at a shortage of dentists in north Wales and whether there is a case for training dentists in north Wales, in Bangor, exactly as has happened with doctors. Because the arguments are the same: if you train people in a particular area, they do tend to remain in that area, and in that way, they do fill in those gaps that exist in many areas across north Wales. So, I’m sure you will have heard me making the case about doctors. Well, I think the same arguments can be made about dentists too. Thank you.

I thank the Health, Social Care and Sport Committee for the report on dentistry in Wales. NHS dentistry in Wales is in crisis. Less than one in five practices in Wales are taking on new adult patients, and just over a quarter of practices are offering appointments to new child patients. We regularly learn of patients making round trips of 100 miles to see a dentist. It's not unusual to see practices who open up to new patients have 10-hour queues outside the door and there have also been extreme cases of people doing DIY dentistry because they can't see an NHS dentist and certainly can't afford private treatment.

As the committee quite rightly highlight, the main culprit is the dental contract, which sets unrealistic targets and quotas, preventing dentists from treating more patients. The NHS general dental services contract also discourages dentists from taking on high-needs patients, particularly in areas of deprivation where there is already poor access to the dental services. Not only is the UDA system not fit for purpose, it has also actively harmed oral health in Wales. 

I am pleased, therefore, that the Welsh Government has listened to the committee and agreed to scrap the target system rather than tweaking it as they did in 2011 and 2015. I would go further and urge the Welsh Government to ensure the new UDA arrangements also prevent dental practices from insisting on six-monthly checkups and abide by NICE guidelines. The chief dental officer for England said that, in the majority of cases, check-ups are only necessary every 12 or 24 months, and this will not only ensure patients aren't forced to pay for unnecessary treatment, but will allow practices to take on extra patients because this time will now be freed up. So, hopefully, the improvements put forward by the committee will put an end to long trips, longer waits and instances of people pulling their own teeth with a pair of household pliers. Thank you.

Thank you. Can I call the Minister for Health and Social Services, Vaughan Gething? 

Thank you, Deputy Presiding Officer. I would also like to thank the committee for their report and their inquiry into dentistry in Wales and to Members who contributed to the debate today. The recommendations do broadly reflect Welsh Government policy and recognise some of the progress made to date, whilst identifying where further work is still required. We acknowledge that the current dental contract needs reform, as commented by all Members in the debate. Units of dental activity, or UDAs, should not be the sole measure of contract performance. They do not reflect or incentivise a preventative or team approach to care. However, calls to bin the UDA are too simplistic and don't offer an alternative.

The Llywydd took the Chair.

Whole-system change is already under way in dentistry in Wales. We need clinical teams in health boards to collaboratively agree on what to deliver and how to measure excellence in primary care dentistry. New approaches to contracting with more meaningful measurement is already allowing patient need, practice-level quality, team workforce and access to be better understood. This is more than making a few tweaks with the contract. Dentists, dental care professionals, health boards and academics are working together to shape and deliver transformation in line with 'A Healthier Wales' by removing financial disincentives so dental teams can focus on prevention and make use of the skills of the whole team.

The dental reform programme is focused on quality, prevention and access. From this month, a further 36 practices are joining the existing 94 participating dental practices in contract reform. That represents about a third of all dental practices in Wales who are taking part. In contrast, in England, just over 1 per cent of dental practices are taking part in their contract reform programme. However, we want the pace of change to quicken even further so that more dental practices can work in new ways. I expect over half of all practices to be part of the reform programme by October 2020, leading to a full roll-out of contract reform in 2021. The broader set of monitoring measures and the removal of low-value UDAs under contract reform will help to reduce the need for health boards to recover funding from dental contractors. I have asked health boards to report on any resources recovered, and I expect them to provide year-round support to dental providers who experience difficulty in meeting targets.

We know recruitment and retention in the dental workforce causes difficulty in a number of areas of Wales. There is more to do to address the multifactorial issues involved. So, Health Education and Improvement Wales are looking at training numbers, ways to help develop the workforce, and are considering alternative workforce models to support delivery, enhance recruitment and incentivise retention following training. In addition, the All-Wales Faculty for Dental Care Professionals being established at Bangor University, which I expect to visit in the new year, will contribute to career opportunities for the dental care professional workforce.

The dental e-referral management system mentioned yesterday covers all dental specialties, including orthodontics, and has been successfully rolled out nationally. We are the first country in the UK to implement a fully electronic system for all dental referrals in all dental clinical specialties. That now means that the source, complexity, and volume of referrals for dental specialties will be known by health boards. And in turn, that supports evidence-informed workforce planning and paves the way to service redesign, with a shift out of secondary care for procedures that can, and should, be delivered within primary care. And, of course, a fortnight ago, we celebrated the tenth anniversary of Designed to Smile, our population child oral health improvement programme. This has made, and continues to make, a significant contribution to reducing dental disease levels, and we're committed to continuing our support for the programme.

There is, of course, more to be done. I'll happily respond again to the committee with a range of the points made that there isn't time to respond to today, however significant steps have already been taken in reforming dental services and improving the oral health for the most vulnerable members of our communities. I hope the clear programme of dental contract reform that I set out to be completed by 2021 will provide the assurance Members are plainly looking for. But I will continue to keep Members updated on our progress in addressing all of the recommendations made in the report.

Dai Lloyd to reply to the debate.

Diolch, Llywydd. Can I thank everybody for their contributions? In the short amount of time I have left, I'll briefly sum up. Obviously, this debate has provided a very welcome emphasis on dentistry and the concerns of dental colleagues, which is not something we do every day here in the Senedd. Can I thank all Members for their contributions—Angela Burns, Siân Gwenllian, Caroline Jones and the Minister?

There are significant challenges, obviously, as we found out in the evidence we took as a committee, because what was clear to the committee is that the current NHS contract arrangements for dentists simply aren't working. Paying someone the same amount to deliver a course of treatment on a patient regardless of the amount of work involved makes little sense.

It's simply not acceptable nowadays that only 14 per cent of dental practices in the old Abertawe Bro Morgannwg area are taking on new adult NHS patients. It's certainly not acceptable either that in the whole of the Hywel Dda health board area not one dental practice is taking on NHS patients. So, the Minister has started on a journey, but the Government needs to take far more action and take that action quickly. Doing nothing is simply not an option. Diolch yn fawr.

The proposal is to note the committee’s report. Does any Member object? The motion is therefore agreed in accordance with Standing Order 12.36.

Motion agreed in accordance with Standing Order 12.36.